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Mike Leavitt, Secretary of Health and Human Services


Boston, MA


Friday, July 15, 2005

Remarks to ASTHO-NACCHO Joint Conference

Good morning. It is a privilege to be with you today for this joint meeting of your distinguished organizations. I want to thank Dr. Michael Caldwell of NACCHO and Dr. Dick Raymond of ASTHO for inviting me. Most of you know that Dr. Raymond has been named Undersecretary of USDA Food Safety � Dick, we look forward to working with you in your new capacity.

As the health officers of our states, territories, counties and cities, you work on the front lines of American health. I appreciate everything you do to help the residents of your states and communities lead longer, healthier lives. And I want to thank you for cooperating with my Department on so many important projects. I know you will be discussing them with Julie Gerberding and Betty Duke later this morning � both of whom are doing a terrific job.

I'd like to talk to you today about preparedness, but I also want to recognize the work you do to protect Americans from threats that touch their lives everyday � threats like diabetes, heart disease and cancer. These are vitally important issues to our Nation's health and to me. And I look forward to discussing them with you at future opportunities.

I want to set the stage for my remarks by reflecting on something that occurred when I was governor. My mind still has a sharp and crisp memory of the 2002 Olympic Winter Games.

It was a magical time for my home state of Utah, and for me personally. It was also magical for the incredible athletes � Sarah Hughes winning the gold against incredible odds, Apolo Anton Ohno winning gold and silver medals in short track speed skating (something I call a combination of ballet and roller derby), and Sele and Peltier, the Canadian figure skaters who accepted a silver medal after a judging controversy, and then accepted a shared gold medal, with incredible graciousness and dignity. From the outside looking in, they were near-perfect Olympic Games.

There is another story: one that has never received much attention. It happened on the fourth night of the Games, just as it was looking like the snow conditions, TV coverage and transportation system were all going to meet our aspirations as a state.

At about 6 in the evening, I got a call. An air monitor at the busiest concourse of the Salt Lake International Airport wasn't right. It had tested positive in four consecutive tests for anthrax. It was the first time any of the monitors had ever tested positive. It was just 150 days since 9/11. My stomach sunk. My security took me right to a health department lab where a more definitive test was underway.

My mind raced with the possibilities of what cunning and evil minds can do. Tens of thousands of people had used that airport concourse that day. These people where now distributed all around the country. Nobody would even know the source of the problem. I worried what the human cost could be.

The exercises we had participated in before the Games helped � we knew where to go, what decisions had to be made, and who needed to make them. I learned the value of infrastructure � the CDC monitoring network. And, I learned the importance of having trained experts nearby. If I had to sum it up � I learned that the best kind of preparedness is within walking distance. My Commissioner of Public Safety and Director of the Department of Health were right by my side.

You know how this event ended. You never heard about it because the final test proved it was a false alarm. The Games went on in brilliant fashion.

It doesn't always turn out that way. We witnessed this just last week in London. Watching those tragic events unfold, how many of us asked the question: "Are we prepared for another attack?" It was the latest reminder of the importance of continuous evaluation of our preparedness efforts.

On several occasions over past months we have used exercises to assess our readiness and to improve capacity. There is one lesson that is glaringly clear to me when it comes to a health emergency. Having stockpiles of medication and supplies is essential, but it's distribution that defines victory. In a moment of crisis if we are not able to deliver pills to people over wide areas in short time frames, lives will be lost.

When a bioterrorism event occurs, the time frames are perilously short. In many cases, if people have taken the right pill within 48 hours they are fine, but every minute after that the chance of death increases. Every minute counts. Those precious hours erode quickly. First it's the period of uncertainty; people are sick, but why? Often there are lags in information flow or communication breakdowns and more questions; how wide an area has been affected; which way will the wind blow; who's in charge; tick, tick, tick, the time erodes.

Once the decision is made to deploy medicines from the stockpile, it's just a matter of hours until the supplies arrive in the general area of need but frankly, that's the easy part. Now, we have to work together to create a distribution system. Presumably, by this time, the news is out. People want medicine and they want it desperately. If people around them are getting sick, the situation gets worse.

Each state has a plan of distribution, but our experience so far makes it clear that we don't have enough points of distribution, and there are problems that have to be contemplated. Imagine the traffic congestion if there were a handful of distribution points within a metropolitan area during a period of wide spread panic.

My conclusion is this: we have to get better at this. In some cases, we have to change the way we think about it, and it may be, we have to change the way we're doing it.

Preparedness and health security are a shared federal, state and local responsibility. We need to come together to create a seamless preparedness network where we are all working together for the benefit of the American people. I've come here today to share with you my perspective, but also, to hear your ideas. As a former governor I know, the best ideas don't always come from Washington, DC.

So today I pose three questions:

  1. How do we improve our preparedness for a chemical, biological or radiological attack?
  2. How do we prepare for an equally serious threat � the threat of a flu pandemic?
  3. And what are the proper roles of the federal government, state and local government in preparing for these threats?

I've not chosen the topic of preparedness because I have any new intelligence or information that tells me an attack is imminent. But, I do know that these threats exist, they are very real, and we cannot afford to wait. In the world of bioterrorism and pandemics, complacency leads to catastrophe.

The President has admonished us that we cannot wait on events, while dangers gather. The threat to this nation of a biological attack and flu pandemic are urgent realities, and they require an unflagging sense of urgency.

On bioterrorism, our country has taken a number of important steps since 9-11.

  1. We have expanded and enhanced the Laboratory Response Network to aid in detection and surveillance.
  2. We have worked with every state to develop response plans to deal with a variety of chemical, biological and other emergency situations.
  3. We have built stockpiles of needed drugs and other medical materiel such as respiratory assist devices.
  4. We are piloting a Cities Readiness Initiative to upgrade capabilities for the rapid distribution of antibiotics across large urban areas during an emergency situation.
  5. We have provided nearly $7 billion since 2001 (including the 2006 budget) for state and local preparedness.

But as far as we have come, we still have much more to do.

We must constantly be asking ourselves if we have explored all of our options to improve the level of preparedness. We should be innovative and not just reject ideas because there are hurdles involved, but find ways to cross these hurdles. We need to think outside the box. I can assure you, the terrorists will.

As I mentioned at the outset, we must find better ways to get needed medicines and materials to people in time to make a difference. The statement of the problem is quite clear�but as you know the answers are less clear and none are perfect.

So we are beginning to have conversations about a range of solutions to this problem from local points of delivery, to home delivery, to having medicines in the home in advance of an emergency.

Understanding that moving emergency medicines into a community is a shared federal, state, and local responsibility, we want to consult with you about a range of modalities. None of them is perfect. Several or all of them could be used in combination depending upon the needs of a particular community. These could include:

  • Classical Points of Dispensing (or PODs) for drugs or vaccines. This is the primary means municipalities currently use. The Federal government delivers material, and local authorities get it to affected people. This mechanism has been used by many communities over many years, albeit not on the scope or at the tempo that a major bioterrorism event would require. We've exercised this a number of times and know its strengths and limitations.

  • Direct residential delivery of antibiotics by postal carriers. We began working with you on this initiative last year. The postal service touches almost every American household. We are working with the Post Office to explore how a cadre of willing, trained postal workers would be able to deliver needed medicines into a large area, very quickly.

  • Predeployed community-based caches of pharmaceuticals for emergency use. Locally stored caches of pharmaceuticals can be at the front lines of an emergency very quickly. We already sponsor such caches in hospitals through the HRSA Cooperative Agreement Program. We are working with some local communities to understand some of the complexities inherent in community caches, such as shelf life, storage and deployment.

  • Pre-event dispensing of pharmaceuticals as equipment to first responders; Our first responders by definition are first on the scene. Providing them potentially needed medicines in advance can better equip them to respond to biological or chemical emergencies � a benefit to us all.

  • Pre-event placement of pharmaceuticals in individual households for use only as directed by public health authorities. This idea would move the medications closest to the potential user. We need to understand better the strengths and limitations of this concept. Examining how we could move medications to the ultimate front line has to be part of our thinking.

The POD concept is the bedrock of mass prophylaxis, and we must do everything we can to make it more effective and efficient. This is the primary purpose of the Cities Readiness Initiative. At the same time, we must recognize that PODs alone are not guaranteed to avert catastrophic loss of life. Therefore, we must give serious attention to other options. We cannot and should not expect that this be approached in only one way, or that every community approach in the same way.

In addition to the threat of bioterrorism, I'm very concerned about what's been aptly named "Nature's Bioterrorist". I'm referring to an influenza pandemic. In fact, the threat of an influenza pandemic is what really keeps me up at night. It's at the top of my agenda, and I can assure you that it is on the President's agenda as well.

I've delved a lot into the topic of pandemics. I've had conversations with epidemiologists and virologists. I've read the graphic historical account of the 1918-1919 pandemic recounted in the book "The Great Influenza" by John M. Barry. This book should be required reading for anyone in public health.

It describes in vivid detail the winter of 1918 when history's most lethal influenza virus started in an army camp in Kansas, extended east with the movement of troops, then skyrocketed, killing as many as 100 million people worldwide. It helped me realize the impact that a pandemic could have not only on health and well being, but its impact on the economy and on national security.

One of the interesting facts you learn in the book is that throughout history, more soldiers often died of disease than in battle from their wounds. And epidemic disease has often spread from armies to civilian population.

We know a catastrophic pandemic is possible. It has happened at least once in our history. Moreover, changes in mobility and travel patterns may mean the impact is even greater in modern times. I believe we're at greater risk for pandemic than we have been in decades.

I am very concerned that the H5N1 virus continues to spread. An article in last week's issue of Nature documenting this virus in migratory geese in Western China is the latest news about the expanding geographic spread of this virus.

While much focus has been on the H5N1 virus � and appropriately so, we also know that other influenza viruses could also evolve into a pandemic threat.

There is a simple rule with pandemics: anywhere means everywhere. We know that an outbreak of a novel influenza virus in even a very remote location could mean that a pandemic could spread throughout the world.

While a bioterrorist attack would likely be localized, a flu pandemic would be global in scope, so we need both an international as well as domestic strategy to deal with it.

At the World Health Assembly in May, I called together the Ministers of Health from the regions affected by avian flu, along with those concerned about pandemic influenza, and I emphasized the need to cooperate and communicate, regularly and without surprises. We discussed some of the near term and longer-term barriers to sustainable action on avian influenza. Soon I will travel to Asia to make a first-hand assessment of the risk and our preparedness.

We've known for a long time that it is the nature of the influenza virus to evolve, and evolve rather rapidly, and pandemics have occurred when new strains emerged. We are watching what is going on in Asia and have invested in the World Health Organization's global surveillance to track what is going on more closely. In fact, in addition to those members of the HHS family that are stationed in the region, there is a team in Asia right now, traveling to many of the affected countries to help guide our next round of investments.

We are also taking a number of steps to prepare on the home front.

  • We are updating the Department's Pandemic Influenza Preparedness and Response Plan knowing that state and local plans need to incorporate federal guidance.

  • I have established a Department-wide influenza preparedness task force to ensure that I get input from across the Department on influenza and pandemic influenza issues and to improve our internal coordination. In addition, we regularly reach out to other parts of the government (USDA, DOD, DHS, State, and USAID to name a few).

  • We have created stockpiles of antiviral drugs and we are adding to them. But we need to know that they will work effectively against this strain and that they can get to the people who need them in time to work. The dramatic increase in resistance to one class of antivirals � likely accelerated by the all too familiar agricultural practice of including it in animal feed � could reduce the impact that these drugs could otherwise have. As you know too well, when it comes to antimicrobial drugs and the development of resistance, when you use them you often lose them.

  • We are making substantial investments in vaccines � in developing a vaccine for H5N1 as well as investments in strengthening influenza vaccine manufacturing and diversifying the technology. We've made these investments as part of our pandemic preparedness initiative, but also know that they will pay off in our annual influenza vaccine supply.

This morning, I am pleased to announce that the Department plans to purchase additional antivirals and additional vaccine against H5N1, which should give our stockpile enough vaccine for 20 million people and enough antivirals for another 20 million people. These new medical countermeasures will give us additional tools to prepare for an influenza pandemic.

We also know that we need to strengthen the systems that we will rely on when a pandemic hits because we will need to know how we're doing, and whether our vaccine and antiviral strategies are as effective as they can be. We will need to be able to make adjustments along the way. Some of the critical activities we are working on include:

  • Improving our surveillance system at home

  • BioSense; BioSense � our nation's national health safety net � provides early detection of disease outbreaks of public health importance. We already collect information from pharmacies about over-the-counter medications and from nurse call lines about reported illnesses and symptoms. We can and will do more. We intend to link reporting data from emergency rooms in select cities so we can improve our near real-time surveillance of potential disease outbreaks. We will use this initiative as a "breakthrough initiative" to achieve common standards and interoperability in health information technology.

  • Ratcheting up our efforts into a real-time system to deliver data faster.

Engaging the public on the issue of pandemic influenza is also something we need to do better. As we approach this year's flu season, we should look at it as an exercise in pandemic preparedness. Are vaccines getting to those who need them most? Do people know where they can get a flu shot? Are we doing our best to understand the dynamics of flu vaccine demand?

These challenges we face with seasonal flu have implications for our success in a pandemic influenza vaccine program.

As we work to improve preparedness for both a bioterrorism attack and a pandemic, we must begin an honest appraisal about the role of the Federal Government. Certainly the Federal government has a key role to play in preparedness, but we all know that the Federal government cannot take care of all our needs. As state and local partners, you must ask what you can and should do.

We need to evaluate if we are spending our money for the right things. As Secretary Chertoff says: "We have to be risk-based in our funding rather than earmarking money for predetermined categories or localities."

In my home state of Utah, for example, we have a small, remote county getting approximately $250 per person � while the Salt Lake area is only receiving about $5 per person. You and I know that this isn't right. There has to be a better way to do this. I look forward to consulting with you about how we can do that.

When I met with several representatives from ASTHO a few months ago, I heard your concerns but also heard your tremendous progress. Among the many points you raised, I was struck by the lessons that were learned in taking preparedness plans off of the shelf and exercising them and by outreach efforts to begin to educate your communities.

Exercises keep us fit. They make us sweat, we get short of breath and may even trip while we're doing them�but in the end they improve our fitness to perform when we need to. A 2003 GAO report pointed out that cities with multiple prior experiences with public health emergences caused by natural disasters and with preparation for special events were generally more prepared than the other cities, which had little or no such experience.

This highlights to me that planning is important, but exercising those plans and critically analyzing the exercises is what is likely to make a difference�and I don't need to remind this audience that in the realm of public health, making a difference may be measured in lives and deaths.

I want to close by taking you back to the Olympics. One of the great perks of being a governor is that you get really good seats. I had front-row seats the night of the figure skating championship.

A sixteen-year old skater named Sarah Hughes skated out onto the ice. She was in fourth place. No one expected her to win.

There were 24,000 people in the arena that night and probably a billion watching from around the world. I was literally at eye level.

I looked Sarah Hughes straight in the eye and there was a sense that she was more relaxed than I could have imagined. The music started. It may have been that she was in 4th place and didn't feel as though she was a serious contender. She clearing was skating for pleasure � a pure love for the sport. The crowd instantly began to feel the rhythm of the music and of her movements. The music stopped. Her arms went back. Her head went up. The flowers were thrown onto the ice.

She had performed like a champion, and, yes, she jumped from fourth place to first place to claim Olympic gold.

The next day at a news conference, this sixteen-year-old girl who in the days before the competition was studying for the SATs, made what I thought was a profound statement. She expressed her gratitude for the opportunity to skate in the Olympics. She said, "Some people never get the chance to skate the performance of their life, and I did."

I would submit that in a very real sense, there are few generations who have the opportunity to work on a public health project of the size and importance as this one. Our preparation could save millions of lives.

We need to skate the performance of our lives. I have every confidence that we will.

Thank you.

Last revised: July 19, 2005


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